Module M
Module M – The Nursing Process and Nursing Care Plan
(S-1) Title Slide
(S-2) Objectives
1. Identify the role of the nurse aide in each step of the nursing process.
2. Describe the importance of a resident’s nursing care plan.
Content
(S-3) Nursing Process
 Method used by nurses to plan and deliver nursing care to the
resident
 Five steps are
o Assessment – collecting information about a resident
o Nursing diagnosis – a health problem that nurses can treat
using nursing measures
o Planning – setting of resident goals that are prioritized
o Implementation – nursing measures carried out during resident
care
o Evaluation – deciding if nursing measures worked or were
effective, and whether goal was met
 Different from what the doctor does regarding care of resident
 A type of game plan for resident care and not simply, hit and miss
(S-4) Nursing Care Plan
 Is sometimes simply called the care plan
 Responsibility of nurse to provide individualized, written plan of
care for residents
 Based on nursing process
 Used for coordination and continuity of care throughout the day
and on a day-to-day basis, for each resident
 May be standardized, computerized, or written in Kardex
o Kardex – a type of card file that includes information important
to the care of residents and includes drugs, treatments,
diagnoses, routine care measures, and special needs
(S-5) The Nursing Process and Nursing Care Plan – Importance
 Nursing care of the resident is organized, individualized, and has
purpose
 Nursing care is consistent and nurses/nurse aides know what is
expected to be done
 Resident feels safe and secure because care is consistent
 Nursing care plan assists health team members to deliver quality
consistent care to residents. Time spent performing unneeded
tasks and care wastes money, resources, and time
(S-6) The Nursing Process and Nursing Care Plan – Nurse Aide’s Role
 Cannot perform assessments, but can assist nurse during data
collection, such as obtaining heights and weights, vital signs,
recording intake and output; need to report timely and accurate
data
 Nursing diagnoses based on data collected and nurse aides often
DHSR/HCPR/CARE NAT I Curriculum – July 2013
Notes
3-M
Module M
Module M – The Nursing Process and Nursing Care Plan
collect data used by nurse to create nursing diagnoses
 Interventions are often what nurse aides do, such as turning,
repositioning, toileting, etc. documenting accurately assists the
nurse with evaluating interventions
 If intervention does not work, nurse modifies nursing care plan
 Most important part during intervention stage is to accurately
report reactions to interventions
 Evaluation is time when nurses look at nursing care plans and see if
plan worked in solving health issues and if interventions effective
 Nurse relies on observations by nurse aides to assist with evaluation
(S-7) THE END
DHSR/HCPR/CARE NAT I Curriculum – July 2013
4-M